Basic Information
| Provider Information | |||||||||
| NPI: | 1073590295 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LACY | ||||||||
| FirstName: | CHRISTOPHER | ||||||||
| MiddleName: | I | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1984 PEACHTREE RD NW | ||||||||
| Address2: | STE 505 | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303095219 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7707792178 | ||||||||
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| Practice Location | |||||||||
| Address1: | 11 UPPER RIVERDALE RD SW | ||||||||
| Address2: | |||||||||
| City: | RIVERDALE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 302742615 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7709918000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/29/2005 | ||||||||
| LastUpdateDate: | 04/27/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 045865 | GA | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 000799499 | 05 | GA | MEDICAID |